Merged: Senate Inquiry

The aircraft was raised and then, before surfacing, dropped back to where it was. This simple interference is tantamount to breaking the evidence chain. Some may argue that this was done to achieve such a legal aim. I have read assurances from Truss that no benefit would be served by the recovery. However one benefit would be to preserve the evidence chain and prevent anyone from having any lingering doubts.

On the other hand, raising the aircraft would put the recorders within reach of recreational divers and not require specialised equipment. This being the reason Australia couldn't justify the financial cost of recovering the recorders from a depth of 40 metres

Ben – "Pel-Air needs to be re-investigated, as best as can now be done, by an independent body. The TSBC was specifically precluded from looking into the actual events and causes of the Pel-Air medical evacuation flight being ditched in the sea near Norfolk Island on 18 November 2009."

But Ben, consider this: there was little wrong with the original ATSB investigation and reporting of the incident. There are very clear indications that the causal chain and peripheral issues had been identified as 'significant' and contributory. The ATSB investigators were all set up to issue some fairly 'serious' safety alerts and recommendations. I believe we need to know why the original intent and report turned out and was published reading very much like the CASA report CAIR 09. Somewhere, 'twixt crouch and stirrup' something changed, that change is clearly evident through Hansard; the reason why it changed is not. Which, of itself is passing strange, as the ATSB IIC and team had no skin in the game: just another day in the office to them, there was no motivation to do anything other than their usual, routine work using 'their' system. There was no motive for the ATSB investigators to do anything other than a 'routine', bog standard report.

I've said this a hundred time before: WHY did CASA not simply put their hand up and acknowledge that ATSB had identified some 'systematic' problems and a lack of oversight. There was a gold star waiting – "Yes Senator, the ATSB did identify some areas where we have been able to improve our auditing and oversight procedures; we have initiated those recommendations, and thank the ATSB for bringing them to our attention". Piece of cake, no skin off, a gold star and a rock solid defence. To act in any other manner would require a powerful motive; I for one, would very much like to know what that motivation was. To persist with, and attempt to justify the 'executive' actions and stance, post incident, placed those people in a very high risk area, even before the Senate called for answers, let alone during an inquiry. It is this element which needs investigation, not the ATSB 'investigation and report'.

Quote:

Ben – "The senators named above have no intention of letting this matter go through to the keeper. They will keep hammering away at this until the matters are cleared up, and Mr Dolan removed from his role at the ATSB, in the process of dealing with more serious safety administration issues."

Ben, I agree, however I must return to my original question – WHY persist, what possible motivation could there be. CASA must have known that the Senate committee would be well briefed, hold solid evidence; and, that to continue attempting to bluff and bully the committee could only, ever end one way. Shirley (and CASA) knew that Fawcett has forgotten more about 'aviation' than most of them would ever know, that Xenophon is an astute man and clever counsel. The opposition, an aviation specialist and legal mind combined to lead a team of hard nosed, streetwise, savvy politicians. Glen Sterle and Bill Heffernan have survived in a sea of connivance, obfuscation and departmental 'sleight of hand' for many years and can smell a fairy story at a 1000 yards, upwind of it. The best way was to admit and minimise the errors, take a wet lettuce leaf flogging and depart the fix. But no, for some reason the manipulation of our national aviation system was defended; at great risk. Why take the heat?, what was so important that made it easier to be publicly 'outed'?, meekly accept the recommendations of the committee, the humiliation and damage? What needs to be hidden so deeply that made it essential to continue the story line? It is this element which needs investigation, not the ATSB 'investigation and report'.

Quote:

Ben - Which is another way of saying the investigation needs to be very, very thorough. We don’t need lying any more than incompetency in the administration of air safety in this country, and if the government is serious about ending this controversy it will insist the new inquiry puts all of these matters to rest, impartially and as forensically, and as fairly in terms of procedure, as may be needed.

Spot on Ben, the only way to get it 'done right' would be to ask the Senate committee to open an inquiry, supported by a 'Mike Walker' type to do the ATSB 'bit', a 'Mike Smith' type to 'look' at the CASA end, a 'Jack Langmead' type of independent aviation 'legal' expert' and an AFP 'investigator' or two; to do the heavy lifting and digging. Have them report directly to the committee which clearly understands 'the game'.

That's not too expensive; not in the grand scheme of things. Not when you consider the amount of money leeched away providing all expenses paid holidays to Paris to attend a 'course' which cost AUD$ 48,000; gods alone know how much is 'fritted' away supporting this grandiose edifice we call our 'safety system'. I believe Australia has paid dearly for a superior system of aviation safety management and oversight, not only has the public been ripped off, but have been well and truly gulled. In the vernacular, we need to know who rodgered whom, why, when, how much it cost and who paid for the party?

Pel-Air is and remains the tip of a very ugly, expensive, potentially dangerous iceberg, with a history of leaving mayhem in it's wake. The solution is as easily identified as the problem; the Senate committee identified it, the Rev Forsyth identified it, the Canadians went as close as toucher to identifying it, so what's the hold up, where's the road block? Every fool in the market place knows the answer. How to get it done?, well that is the minuscule's problem. I just hope Barnaby has the brains to protect his back and quick enough swing the axe.

Doncha just hate it when the keyboard gets all sticky from spilled coffee ferryman!!

A very good post my friend, astute, to the point and aggravates that nagging tickle in the spine when you just know something aint right.

Some one asked in a previous post would anyone employ DJ even without CAsA's witch hunt.

To my mind, "Why the hell wouldn't you?" He's displayed fortitude, courage and courage of his convictions, owned up to his errors, taken his punishment, and very much learned from his mistakes.

There is no doubt he has displayed more integrity than any one of his accusers, and to top it off he's a very competent pilot.

What has our so called safety watchdog learned from Pelair?? As some of the few people who have actually survived such a ditching one would have thought our "Safety" people would have been eager to debrief the crew with a focus on what worked, what didn't, what lessons could be learned, why life jackets didn't work? what the hell happened to the raft?

What was the regulators attitude?, "Your Nicked mate!! anything you say, can and will be used..etc and if we can't find anything to prosecute you with, you'll be handed over to that warm fluffy wabbit's tender mercies for "Administrative embuggerance".

That is perhaps the most infuriating thing about this whole debacle, there were and is valuable SAFETY lessons to be learnt and passed around the industry, all lost because the ego of one man with a long history of anger management issues determined to bully a weak unqualified bureaucrat into accepting his view.

I Agree Kharon, there is something not quite right. Hopefully the truth will prevail.

Couldn't have been the angry man was terrified a negative ATSB report on CAsA might have influenced chances at ICAO???...NA, course not, but as conspiracy theories go???

"If the FDR isn’t there, a criminal investigation needs to be conducted as to who paid whom what amount of money and for what purpose to move it, or, what other circumstances led to its disappearance, or even its return to the site."

What info has led to this statement?

Slats:

Quote:

There have been speculation for some time that the wreckage has been disturbed. It has been rumoured this was done in getting the recorders.

I have no knowledge if this is true or not, but these rumours have been going around for a while.

For those interested this was referenced several times in the infamous closed Senate thread and on here earlier on in the year...

From the PBRP (Pirates Bar Room Plunderers..) the story goes that the rover had roped the tail and the locals were all geared up to retrieve the black box. However then mi..mi..mi beancounter Beaker got the trembles and put the khybosh on it citing OHS issues, decompression chambers and of course limited funds...

...then the locals offered (for next to nothing) to drag the wreck towards the shore where the ocean bed rises up to a depth of 30m, thus allowing recovery of the box through a normal freedive. They again were all set to go and had lined up the local freighter to snag the mooring rope with it's anchor, but again Beaker got all squeamish and refused to give the green light...so..so close but no cigar!

..rumour amongst the PBRP is that the box is now proudly sitting on someone's mantelpiece in yonder Norfolk Isle..

Now you can see why this tale has shades of Hempel, in both cases the necessary crew was ready and eager but the powers to be got cold feet right on the vinegar stroke..

The regulations in force at the time required the recovery of the recorders if possible. For some reason the ATSB sought to play with words and rely on an interpretation of regulations not in force at the time. This was a key reason the Senate committee was dissatisfied with Dolan's evidence ay the inquiry.

At this point the best thing would be for the ATSB to ask an independent body to recover the recorders. Either the RAN or a Police agency. That way we could at least be confident if they were there or had been removed.

If they are present an independent agency (? Canadian TSB) should attempt to recover the data. If there is no data able to be recovered, we need to be confident that this really is the case.

If they are gone there needs to be an investigation into the circumstances of the disappearance.

Last of year for BRB, good turn out, with a couple of notable exceptions (those catching mud crabs, Whiting and laying about swimming pools whilst nubile cheffettes in bikini's toil over the wine cooler and BBQ – scandalous). But, the working stiffs made it.

Part 61 got it's usual workout. The more you try to work with it, the worse it gets was the consensus. Big complaint is actually downloading the thing – CAA NZ go to web site – search rules, part 61 – download and done about 90 seconds all up. Australian CASA – go to web site – search – and go back – search to identify the Volume you need – download; search for the MoS volume supporting – down load; discover that you need another reference volume; repeat process. When you eventually have all eight volumes and try to use it to identify a contentious issue, say a ruling on a check element; it's a long, slow, complex procedure, often involving two 'volumes'; and even then, you are not really sure you've nailed it all down. But the big ticket item for BRB crew is the 'subjective' nature of the beast. It is wide open to helping a fail, as so much depends on the latitude given for the 'opinion' of the check pilot. That it has go - all of it, was, once again unanimous.

The Pel Air investigation being re opened had the lions share of 'air time'. Two items were worth reporting back, RVSM issues, and a possible solution as to why such extraordinary actions were taken by both CASA and ATSB.

The RVSM issue has been a quality 'sleeper', quietly snoozing away in the backroom. If ATSB are to get 'fair-dinkum' then the complaints and warnings, particularly those of James must be taken into the matrix. The BRB were curious to know why the matter was not considered as part of the causal chain. It was critical to fuel uplift decisions and a 'peripheral' consideration which could affect the basic 'planning' logic for the pilot. Be interesting to see what is made of this issue. Why it never made it, in any meaningful way into the report, is one of the many questions unanswered the first time around. Unanimous – RVSM (lack thereof) must be considered in the next iteration.

The why's and wherefores of the post incident handling of the Pel-Air ditching by the 'authorities' has long been of interest to the BRB; and, is never far beneath the surface of any discussion, simply because it ran so breathtakingly close to an outright, blatant disturbance of so many tenets. We were presented a well reasoned argument with enough legs to be worth reporting. The potted version:-there was a plan to subsume ATSB into CASA. From a simple financial premise it makes some sense; it also removes the 'independent' ATSB thorn from the CASA rump. It explains why CAIR 09 was drafted, why the incoming MoU was used rather than the 'existing'; why ATSB was hugg-mugga with CASA and the 'spirit' of cooperation was embraced. There would be bonuses, applause and total control of 'investigation' resulting. This would need some 'political' support, but as we all know Albo was a great fan of McComic and would support any notion presented, provided it took 30 seconds or less to pass over his desk. Food for thought?, ain't it though. MTF on this, methinks.

The BRB was absolutely, completely unanimous ATSB must not be allowed to 'control' and limit the scope of the Pel_air investigation; the simple fact that Bea-Cur was prepared to confound Fawcett by using a 'later' version of the ICAO annexe 13 to support leaving the recording unit on the ocean floor is enough to cast doubt over any future ATSB efforts. As long as he remains in charge – every word uttered must be suspect, especially when he speaks with 'his masters voice'.

The infamous MoU and changes required to Acts once again drew some fire; but that discussion was deferred as the opposition darts team turned up and the real purpose of the evening became apparent. [email protected] sights concealed in lampshades were allowed, in the spirit of Christmas, but as we soon discovered, putting a green dot on double top, don't mean you can hit it. Safe home you guys, a most enjoyable evening.... Later, walking home with P7, not much said until his front gate, "Much to ponder" say's he. "Aye, there is" says I.

Yes indeed the lack of RVSM was one of many holes that lined up that night. This has been overshadowed by other issues, but the lack of RVSM played a critical role. The need to be able to climb above RVSM airspace was presumably the reason full fuel was not uplifted at Apia. Full fuel would at least have allowed a few more approaches at Norfolk, and maybe they would have got a break. More importantly, full fuel may have made diversion to Noumea an easy decision when DJ first became aware of deteriorating weather at Norfolk (by the time he became aware, it was not clear he could reach Noumea).

With no RVSM, the only way they could have flown Apia - Melbourne and carried an alternate would have been to go via Noumea, or Nadi & Norfolk (shorter than Noumea, but two stops).

Its difficult to escape the conclusion there were a lot of corners cut, and they were very exposed to any bad luck (unexpected headwinds, deteriorating conditions). The CASA special audit reviewed PelAir's records, and determined there were three instances over the previous couple of years when PelAir landed at Norfolk without alternate fuel (well, two landings and one ditching). Sooner or later the holes were going to line up.

That statistic itself is striking. Three flights to Norfolk without alternate fuel, and only 2 successful landings.

The real question is on whose watch were all these corners allowed to be cut. Most people here feel DJ should carry some responsibility, but only some.

I think the CASA subsuming ATSB would be a symptom of CASAs pathology.

The real issue is that CASA believes that it is the master and one true source of aviation saftey knowledge in the universe. All the problems the IOS (and certain Senators) have with CASA stem from this belief - CVD, Part61, PelAir, the general paternalistic condescension for the IOS, the contempt they hold when impertinent senators make inquiries.

Any report that questions this belief must be amended or hidden so there is no hint of a duck-up.

Until CASA sheds this belief we will not see an improvement in relations.

Concepts like SSP, SMS, Risk Management systems, and "outcome based" regulation are steps that make everyone (including us IOS) knowledgeable in matters of safety.

Shadow-on-Water; (like the handle) we are temporarily out of Choc frogs; here, have a lump of Christmas pud for a 'nice' point, well made. The problem those who need to denigrate the IOS have is that most of them cannot answer a simple question in response to the braggadocio; it goes like this " I have a wide range of experience, and 5999 hours". - "Oh aye – doing what, in what?" says I.

You won't know; at our humble, but great fun BRB last night the opposition darts team, had almost 50, 000 hours, current flight experience, across a fairly wide range of aircraft and 'operations'; but wait, there's more. Among the crew there were no less than three 'major' air safety oriented 'academic' publications, many years of negotiating both policy and procedure as check, test and chief pilot at local NAA and company level. One IRE/ TRE/ TRI, one senior check and two training captains. Not that they would ever say a word, no need to; you just know they are the real McCoy. (Can't shoot for shinola though, I never bought a beer all night). Yuk, yuk, yak......

I have bumped a couple of CASA 'airline' level fellahin who can hold their own in a discussion with this calibre of crew and they were worth listening to as they 'understood' what was required and 'understand the operational game. But; ye gods down in the weeds at GA and regional level; very few "FOI" have ever been 'chief pilot', not of a real outfit. Even less have ever written a policy, procedure or FCOM; not one from scratch, and most certainly not all of their own work. Not one which may have needed 'negotiating' through an acceptance procedure. It's a part of the problem, compliance with minimum standard only, nothing innovative or efficient will be countenanced; why?. Well simply a lack of 'real world' operational reality and experience. Have a look at the NFI doing Hoods old job; look at what's running 'international' then, turn your mind to South Australia and investigate the great international AOC rip off, or even Part 61. It is good Sirs, truly disgraceful.

Back in the day we respected and grudgingly admired our twice a year interlocutors, who pushed and shoved us into adopting a 'professional' outlook and learning 'grown up thinking'. These buggers nowadays can barely fly an aircraft; not without extensive 'how to do it' checklists and an FCOM to choke a horse. Many do not hold a professional level licence, not one that would get them hired anyway.

To get any change at ground level is difficult. Hell it's tough enough to get the Senate, Forsyth and the TSBC major recommendations even onto the front burner, let alone get an examination of the impact the dross and leavings of industry have on 'operational excellence'. I could go on; but those who know, require no explanation and those who do not are quite happy with the status quo. Why waste wind.. The IOS, PAIN, the BRB are all very aware; getting the 'top level' message through, even with the inestimable Fawcett helping has been 'difficult'. Until there is a forum where the dishonest, dysfunctional, dyslexic and the inutile are forced to answer, confess, resign and repent; GA and regional are stuck with what is left standing; such as it is.

It's got nothing to with money Minister, there are those willing and able to 'assist', if only for national pride. But if the bridge has issues, it is unreasonable to expect the engine room to fix her up. Bring in Mike Smith; Mick Quinn or Greg Vaughan to help 'young' Skidmore:– I'll take LOA and work for any of them, so will my mates. It's fact you would have never before or will ever be likely to witness again, just how stellar and brilliant Australian aviation could become. Cheap, cheerful and most importantly – QUICK. Hopefully, mostly done, before the Yanks, on ICAO credit cards lob up. It is, your shout Minuscule; and it is - yours alone..

Kharon - The potted version:-there was a plan to subsume ATSB into CASA. From a simple financial premise it makes some sense; it also removes the 'independent' ATSB thorn from the CASA rump. It explains why CAIR 09 was drafted, why the incoming MoU was used rather than the 'existing'; why ATSB was hugg-mugga with CASA and the 'spirit' of cooperation was embraced. There would be bonuses, applause and total control of 'investigation' resulting. This would need some 'political' support, but as we all know Albo was a great fan of McComic and would support any notion presented, provided it took 30 seconds or less to pass over his desk. Food for thought?, ain't it though. MTF on this, methinks.

A wise old knuckledraggeronce said: A good mate of mine who has been a CP a couple of times over and then a white hat FOI; over a few beers one day mentioned that after the Lockhart River tragedy & the subsequent fall-out (embarrassingly revealed in both the ATsB report and the Coroner’s inquest) - the edict from above was that a grand master plan -GMP(2) - had been hatched to subsume the ATsB/BASI.

At the time I did question how such a GMP(2) would be allowed under the auspices of ICAO Annex 13 & the relatively freshly minted TSI Act. My FOI mate said that it is possible because the Kiwis had been doing it for years very successfully and without ICAO - it seems - passing one comment over the arrangement.

He finished by making the prediction that if this GMP(2) were to succeed it would be the beginning of the end for a once thriving GA industry in Oz.

Fast forward to the PelAir inquiry hearing 15 February 2013 and on the subject of the 2010 MoU provisions & reports we get this contribution to the debate from Dr Aleck:

Quote:

Dr Aleck : …I was very closely involved in the development of the MOU and the situation that preceded it. If I could just say something that might put some context for both Senator Fawcett's question and Mr McCormick's answer, it might help a bit. Firstly, the rationale for the new MOU was to create an environment in which, if I may put it this way, as much information as appropriate could be exchanged between the agencies. The motivating factor at the time had far less to do with any concerns on the part of the ATSB with information CASA was not providing to them but rather information that the ATSB in the past had not provided to CASA. The fact that the provisions read the way they do reflects a very appropriate form of reciprocity, in which the ATSB under its new leadership said, 'Yes, we will provide you with more information, and we expect you to provide us with the same.' In the spirit of that arrangement, and I agree it probably should be read largely, the question should that a default position should be: 'We'll give you as much as you possibly can and then you decide when we've given you too much.' By the same token, there comes a point where the question has to be asked: 'Is this relevant?' I do not have it in front of me at the moment, but I think the provision talks about reports. To be sure, there was a report there because it took the form of a report, and that is what Mr McCormick asked for. It is quite conceivable that this information could have been developed within CASA in a form that did not take the form of a report, and that would be playing smart: 'We'll put it in this form so it doesn't go there…

“..This would need some 'political' support, but as we all know Albo was a great fan of McComic and would support any notion presented, provided it took 30 seconds or less to pass over his desk…”

The McComic appointment by the Murky Machiavellian team was indeed a masterstroke - in M&M’s other GMP(1) to decimate the GA (IOS) industry - but so too was the appointment of Beaker as CC to the bureau. A position that Beaker was vastly under-qualified for, especially considering that over 90% of all ATsB investigations are generated from aviation accidents/ incidents and neither one of the two other (part time) commissioners had come from an aviation background (i.e. boats/trains) – but he did have a head for figures and a history of spitting out weasel words if & when required...

Senator FAWCETT:Did you have an underspend in your budget this year, last year or the year before? Mr Dolan : There have only been three complete financial years now. In the first year—in the first of my years of stewardship of the organisation—we had a slight underspend. In the last two years we have had slight overspends, but always within less than one per cent of our allocated budget.

Senator FAWCETT:You have not considered outsourcing any of the work or insourcing extra capacity to expedite the production of reports?

Mr Dolan : Our resources are largely tied up in maintaining our existing investigative capability, who are permanent staff of the organisation. We have a longstanding view that in almost all circumstances it is better to have, if possible, the range of expertise available to us on a permanent basis and therefore immediately available than to rely on potentially risky external outsourcers.

Senator FAWCETT:I am not talking about normal operations. I am talking about a situation where you have a budget underspend and a clear excess of work. Was it even considered? That is all I am asking. Mr Dolan : In that small underspend, no, we did not consider it.

Senator FAWCETT:…Even if it is only for one in 1,000 flights and your probability of occurrence is very low, given the cost of action is also very low, why does your process exclude consideration of something that to the common man in the street seems like common sense? Why are we not seeing logical, reasonable recommendations coming out of ATSB reports to an address in this case two things, either of which probably would have prevented the accident? Mr Dolan : There are two things there and I will go to the question of recommendations before I get to the specifics of your question. The ATSB at the point where it became independent of the Department of Infrastructure and Transport also got a shift in its powers in relation to the making of recommendations which raised the ante with recommendations and their significance. There is a legal requirement to respond to each of the recommendations we make. In recognition of that we set up the system of identifying safety issues that said there needs to be a critical or a significant safety issue before we will explicitly use that power to make a recommendation and require a response, and we would generally limits recommendations to those sorts of things. What you are talking about we would in our normal framework, given what you said about likelihood and consequence, deal with as a safety issue without going to recommendation. That is the context: it is still there but your question remains.

The answer is we assessed the facts of the information made available in the course of the flight, the number of opportunities to receive information and to absorb it. We said that that did not seem to indicate that there needed to be any change to the system. That is a matter that others based on those facts could form different views on, but the view we formed was we did not see anything that needed to be done to enhance that system.

There was also the Bea-Cur ego/confidence that his own waffle would be more than enough to put down any potential Senate (IOS) up-rising…

"...At the simplest level, the answers to the Senator's questions are straightforward - and a fair amount of the information is publicly available.

We are prepared to answer them in whatever forum they arise (with the exception of anonymous rumour sites and some tendentious bloggers)..."

No IMHO there is much to like about the BRB Xmas hypothesis…

MTF with Part two including the originally hidden CAIR 09/3, the cunningly crafted 2010 MoU & the attempt to obfuscate the Pel-Air duck-up…

The Witchdoctor has been silently playing the CASA game for over 20 years. He should be best described as one of the 'faceless men'. He has played a big part in what our industry has become today. No large decision bypasses him. Whether it be dodgy, convoluted ridiculous regulations, MOU's with supposedly independent authorities, promotion of executive bullies, or clusterf#cks such as the CVD issues, his DNA is all over it. No claim of 'it wasn't me, I was in Montreal working for ICAO' will fool some of us. Smart guy who knows how to keep his beard beneath the radar, but those who know and understand the real mechanics of CASA and have walked miles around the corridors of the big 'R'' regulator know who the real puppet masters are I've said it before, "there will be no change to how CASA operates when you have people like Chairman Hawke, Dr Voodoo, the A380 assistant DAS and Pumpkin Head from the department steering the ship. You show me a clean sweep of the deck and I will promise you that someone is listening and honest change is imminent'. But I am betting all that you want that nothing is going to change. Please prove me wrong, please.

In the meantime fellow aviators, enjoy the festive season and for some, a well warned break. Be on the watch for CASA Inspector Plod and his merry DAMP men! To CASA management - we look forward to playing the same tautological and tendentious game in 2015. To CASA FOI's - I look forward to flying to and from my property, maintaining my own aircraft and applying my own interpretation of the rules. Catch me if you can, wankers. To Senators X, Sterle, Heff, Forsythe, and others - thankyou for your time, effort and dedication in trying to right the wrongs of a rooted industry. Although in vain we appreciate your tenacity and dedication.

Addendum to Part 1: Before we move onto part 2 it is worth noting that just prior to the Doc's insightful spiel on the 2010 MoU etc. - Senator Fawcett had this to say in regards to the 'passing strange' dichotomy that was facing the Senate Committee...:

Quote:

Senator FAWCETT:I accept the fact that the detail, if you like, of some of the issues that were found with the operator ended up in the reports.The issue here, as you correctly point out in most of your written and oral evidence, is that the pilot is the last line of defence and is a key part. The operator is another one. As you correctly point out, many of those things made their way into the report. But the oversight by the regulator is a third tier and that is what is missing from the ATSB report.It is clear that CASA had in its possession, through these reports—and this is where the Chambers report differs from the special audit. The Chambers report is CASA's own assessment of how it performed its oversight role, which is why, to use your term, it appears 'passing strange' to the committee that there should be such strong rebuttal against witnesses who say we do not think the surveillance was adequate. There was very strong rebuttal, in a public space, saying 'CASA rejects that', when you know your own internal investigations by senior managers are saying that your oversight was inadequate.We are happy that you are taking steps to correct it. Surely it is in the public interest, rather than us having to drag it out through a committee process like this. There were inadequate processes. The ATSB should be provided with that information so the public have confidence that you recognise there are problems internal that contributed to our culture, environment and practices by pilots that led to an error and an accident. The public should have confidence that, regarding the organisational characteristics and culture as such, (a) you are learning—and yes, that is good and (b) that you are also transparent and will say 'ATSB: yes, we were making mistakes in the past and we are addressing it, but here is a report of our own assessment.' For you to say in things like this rebuttal, in quite strong language and with absolutely no hint of compromise, that you reject any assertion that your oversight may have been inadequate when your own internal reports are damning in that area, is surely not in the public interest, nor does it inspire public confidence.

Then there was this in response to Dr Aleck's statement:

Quote:

Senator FAWCETT: I have a comment as opposed to a question. Dr Aleck, you made the point about internal reports not being made public. I just wish to make the comment that if CASA had made this report available to ATSB in an open and transparent manner, as required by the MOU, the report would not have been made public. ATSB probably would have included some facts that CASA had recognised that they were deficient in some areas—and the report does, despite your comments, recognise that areas of the oversight were in fact deficient, not just undesirable. That would not necessarily have been made public, but it would have informed the report in terms of an approach to aviation safety that would give us a good basis going forward.

The second point, Mr McCormick, is that you pleaded the case that CASA cannot do everything; you cannot police every corner. I accept that. I understand that departments are resource constrained. But there are two issues. First, part of the purpose of a safety investigation is to ask, 'Is the resourcing adequate?'—and, if it is not, for the government to then be required to respond to a recommendation out of an ATSB report that perhaps more resources are required in an area. So, to just not disclose that is not actually an adequate answer. Second, in terms of things like FRMS, the work had already been done by CASA—two officers of CASA had done the work. My understanding from the documents is that you had peer review and comment from organisations such as the CAA, which gave a very clear indication that in using a more advanced fatigue management system the flight that was undertaken would not have been approved under an FAA-endorsed fatigue management system.

Now, that requires no additional effort, minimal additional resources on behalf of CASA—except perhaps an email to advise the ATSB that fatigue was probably a causal factor in why the error was made by the pilot. Yet that was not disclosed, as the MOU clearly indicates it should have been.

Which IMO gives further weight to the BRB Xmas hypothesis i.e. GMP(2).

For now though let us move on to the once hidden, infamous CAIR 09/3 and the established connection with the 2010 MoU.

It can be seen that besides the addition of para 9.3 the two MoUs basically remain in effect for the same period of time, with the same conditions for varying, extending or terminating. From that one has to question how it was possible for the PelAir parallel investigation to have been conducted under the guidance of the 2010 MoU, when it was yet to be officially executed. Maybe there had been an ‘exchange of letters’ between Beaker & McComic which had terminated the ’04 MoU. However that would have meant that such agreement between parties would have necessitated bringing forward the official execution of the ’10 MoU and we know that didn’t happen. We also now know that FF were at least operating to the DRAFT version of the ’10 MoU in conducting their PelAir parallel investigation...

From the infamous (previously hidden) CAIR 09/3 report:

SynopsisThe Accident was notified to the Australian Transport Safety Bureau {ATSB) who in turn notified the Civil Aviation Safety Authority (CASA) on Wednesday 18 November. The ATSB decided to conduct an investigation. The CASA Manager Accident Liaison and Investigation Unit (ALIU) was tasked with conducting a parallel investigation for CASA purposes. An investigation into the circumstances of the accident was commenced the next day.CASA informed the ATSB of the investigation in accordance with sub section 4.1.2 of the joint MOU...

And then further down:

Quote:

...Now I know that there is ample political/legal wriggle room in all this and that the MoUs are not in fact legally binding, but it does bring me to my déjà vu moment i.e. the mysterious 3rd MoP.

Now here is what is supposed to be the same document that continues to be readily available off the Senate PelAir inquiry webpage: Current (B, C & D i.e. Attachment 5). Except the attachment has shrunk and is now only 82 pages?? Some may think that this is merely the RRAT committee Secretariat cleaning up the files (i.e. getting rid of blank pages or double ups). However I seriously don’t think that any officer of the Secretariat, no matter how OCD they may be, would even contemplate altering a published & protected under Parliamentary privilege document, it would be akin to career suicide.

So there you go, has a person or persons unknown (& for reasons unknown) deliberately altered a Parliamentary document ?(i.e. a possible third MoP??)...

Q/ The next question is why?? After all the MoU is not a legally binding document.

Q/ Does it matter?? Probably not but considering the timeframe for this deliberate act (between the dates 15 February ‘13 to 01 March ‘13) and some of the references contained within the FF sup submission, I have some strong suspicions on motive…

Now if the average person at the back of the room put those questions I posed back then to the BRB Xmas hypothesis well I'd say the fat lady is now singing the chorus... However if your still unsure take a look at the following references from the 2010 MoU, keeping in mind that apparently (according to the TSBC records) there never was a CASA observer delegated to the ATsB investigation:

Quote:

4.1 Parallel investigations:4.1.1 The ATSB may undertake 'no-blame' safety investigations in accordance with the TSI Act and CASA may separately undertake investigations with a view to possible safety-related action pursuant to its functions underSection 9 and/or Part IliA of the Civil Aviation Act.

4.1.2 As soon as reasonably practicable after either the ATSB decides to conduct an investigation, or CASA decides to conduct an investigation in relation to a matter that would be a reportable matter to the ATSB, each organisation will notify the other organisation.

4.1.3 If either organisation considers an investigation conducted by the other organisation is creating an unreasonable impediment to the performance of their functions, they will raise the matter with the other organisation.

4.1.4 With respect to its own investigation, each organisation will seek to gather evidence from original sources in the first instance and then, where practicable, on the basis of information provided by the other organisation.

ATTACHMENT A- Participation in investigations

1. Participation in investigations will be co-ordinated through the Manager ALIU, CASA and the Director Aviation Safety Investigations, ATSB.

2. The Organisations may agree that a CASA officer may act as an observer or an external investigator for the purposes of an ATSB safety investigation under the direction of the Investigator In Charge (IIC). The CASA Officer will be required to sign an agreement acknowledging his or her obligations and duties, appropriate to the level of their involvement in a transport safety investigation.

3. The CASA Officer will be given access to evidence to the extent necessary to enable the IIC to effectively complete the investigation.

4. The ATSB will not normally seek to participate in CASA regulatory investigations, but may request participation in, or information from, any investigation undertaken by CASA. ATSB Officers who participate in a CASA investigation must comply with any lawful direction given to them by the CASA Officer-in-charge of the investigation.

So join your own bloody dots but the BRB Xmas hypothesis gets my tick of approval...

Good work Sarcs, first class. The joining of all the dots leaves a very ugly picture. Like the airports scam, once you get past the hall of smoke and mirrors it's easy enough to see the hideous machinery driving the show. It is a daring plan and the 'explaining away coincidence' work shop must be going at it hammer and tong to shuffle enough waffle between the layers attempting to achieve some 'credible deniability'.

It all becomes passing strange when you run the chronology of events in parallel; starting from the great airport sell off. The embuggerance of GA operators commencing with some new 'appointees', the beginning of some truly dreadful accident reports, the 'under-spend' on budget, the reduction in the number of investigations; the shedding of two centuries 'talent', the spirit of cooperation blooming large; joint this, team that, CAIR 09/03 carefully tucked away behind a hedge of deadly boring 'paperwork'; the McComic stance and the actions of his minions. All working together to foster and promote safety, the national interest and all matters aeronautical.

Such a fine effort, we should all be applauding. Those purblind Senators should be run out of town by the Murky Mach crowd and subjugated to the will of the hoodoo of Voodoo tribe. By Jove, I love a 'lucky country', don't you??

Enough; the sled needs a wash, the reindeer need a feed and the Northern lights are whispering their seductive message, time to fly. Later.

Big question was asked recently, I must confess the answer required very little head-scratching and muttering. Are "we" going to tolerate an internal ATSB 'peer' review of the ATSB reporting of Pel-Air ditching?

The short answer is no way. When you get right down into it the questions raised by Sarcs (above) which barely scratch the surface, it becomes clear, we cannot. For starters, the 'terms of reference' have been prescribed by one of the three ATSB 'executive' who have the most skin in the game; that, standing alone, is enough reason for doubt. Given the exposure of both CASA and ATSB 'disingenuous obfuscation' during the AAI inquiry, supported by the narrow ToR which restricted the TSBC review; even working toward a 'balance of probability' outcome, it becomes apparent that the 'fix', if not overtly in, may be reasonably expected to be finessed into play.

Karen Casey v Pel Air is due for a hearing in February: if for no reason other than ensuring the deck is not stacked before this aberration gets to the court steps; any inquiry which impinges or is even remotely connected with Pel-Air MUST be seen as being completely free of any possible outside influence or 'clever' manipulation. It is a national disgrace that even someone in rude health must face such an ordeal in court for simply being an innocent, working aircrew member; let alone someone who has lived through five hellish full years of mental anguish and physical pain. If there must be a court hearing, it is up to the aviation community and the parliamentary 'friends of aviation' to ensure, at very least, that the playing field is a level one.

The Senate AAI team should be begged, (coerced, bribed, bullied or pleaded with) to oversight the 'new' investigation into the incident. It is imperative that the ATSB and CASA actions, subsequent to the event are examined to define as clearly as possible what transpired between the incident occurring and the now penultimate report being published.

The following definitions are from ICAO and NTSB:

Quote:

International Civil Aviation Organization (ICAO) and National Transportation Safety Board (NTSB) definitions are included below for reference.

Accident

ICAO defines an “accident” as follows:

Accident. An occurrence associated with the operation of an aircraft which, in the case of a manned aircraft, takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, or in the case of an unmanned aircraft, takes place between the time the aircraft is ready to move with the purpose of flight until such time as it comes to rest at the end of the flight and the primary propulsion system is shut down, in which:

A) A person is fatally or seriously injured as a result of:
■ Being in the aircraft, or
■ Direct contact with any part of the aircraft, including parts which have become detached from the aircraft, or
■ Direct exposure to jet blast, except when the injuries are from natural causes, self-inflicted or inflicted by other persons, or when the injuries are to stowaways hiding outside the areas normally available to the passengers and crew, or

B) The aircraft sustains damage or structural failure which:
■ Adversely affects the structural strength, performance, or flight characteristics of the aircraft, and
■ Would normally require major repair or replacement of the affected component, except for engine failure or damage, when the damage is limited to a single engine, (including its cowlings or accessories), to propellers, wingtips, antennas, probes, vanes, tires, brakes, wheels, fairings, panels, landing gear doors, windscreens, the aircraft skin (such as small dents or puncture holes), or for minor damages to main rotor blades, tail rotor blades, landing gear, and those resulting from hail or bird strike (including holes in the radome).

C) The aircraft is missing or is completely inaccessible.

NTSB defines an “aircraft accident” as follows: Aircraft accident means an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage. For purposes of this part, the definition of “aircraft accident” includes “unmanned aircraft accident,” as defined in 49 C.F.R. 830.2.

Serious Injury ICAO defines “serious injury” as follows: Serious Injury. An injury that is sustained by a person in an accident and which:

A) Requires hospitalization for more than 48 hours, commencing within seven days from the date the injury was received; or

B) Results in a fracture of any bone (except simple fractures of fingers, toes or nose); or

1) Requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; 2) Results in a fracture of any bone (except simple fractures of fingers, toes, or nose); 3) Causes severe hemorrhages, nerve, muscle, or tendon damage; 4) Involves any internal organ; or 5) Involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface.

Substantial Damage NTSB defines “substantial damage” as follows: Substantial damage means damage or failure that adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component. Engine failure or damage limited to an engine if only one engine fails or is damaged, bent fairings or cowling, dented skin, small puncture holes in the skin or fabric, ground damage to rotor or propeller blades, and damage to landing gear, wheels, tires, flaps, engine accessories, brakes, or wingtips are not considered “substantial damage” for the purpose of this part.

ICAO does not define the term “substantial damage.”

I have 'borrowed' the PAIN Zippy account to provide a download link for the latest offering from Boeing, it provides a world class example of 'how to' set about the task of safety analysis; compare it to CAIR 09/03, the "Chambers' report and the Pel Air report. Then ask yourself – what type of report are we, the industry, going to allow one of our own to go into a court hearing with.

If you cared enough to draft and provide submission to both the Senate inquiry and Forsyth review' or, are concerned about the quality and integrity of the Australian national aviation safety systems, to send a short email, to the Senator of choice, requesting that 'they' continue the task which began with Pel-Air and finish the job. You know it needs doing, and doing right.

Okay so the Miniscule has essentially forced the ATsBeaker hand in doing what they - Bea-Cur & by association the 2 other commissioners, Julian, Sanga & M&M - have been strenuously avoiding doing for over 2 years. Wouldn't you think that now would be an appropriate time for all the above mentioned associated parties (DIPs) to step aside and let a real independent AAI - totally devoid of all self-interest/ self-preservation etc. - transparently conduct the re-opened investigation (as is possible under certain provisions of Annex 13)??

Well according to the 'to & fro' missive(s) from ATsBeaker it is simply not going to happen and the TOR of the re-investigation is laced with the usual get out of jail, forked tongued, weasel words. Example..

...A new investigation team will review the original investigation and associated report in the light of any fresh evidence and other relevant points raised in this and separate reviews by the......The main focus will be ensuring that the specific findings of the TSB review are taken fully into account before issuing a final report of the reopened investigation...

Quote:

Kharon - The Senate AAI team should be begged, (coerced, bribed, bullied or pleaded with) to oversight the 'new' investigation into the incident. It is imperative that the ATSB and CASA actions, subsequent to the event are examined to define as clearly as possible what transpired between the incident occurring and the now penultimate report being published.

Pretty sure there is at least one Senator that won't need much coercion if any...

From Additional Estimates Feb 2014:

Quote:

Senator XENOPHON: Do you think it is appropriate? Is it a case of Caesar judging Caesar, because you need to determine whether it is new, which usually can be fairly objectively determined, but whether there is both new and significant material? Do you agree that that is something that can be the subject of a judgment call by the very essence of determining whether something is significant or minor?

Bea-Cur subsequent replies to the NX line of questioning had him steadfastly hiding behind the TSI Act...

NX did get a very significant admission from Bea-Cur which unsurprisingly M&M belatedly tried to counter:

Quote:

Mr Dolan : I would totally agree that this is a matter of judgment. This is a matter of judgment, which under the Transport Safety Investigation Act is given to the ATSB as constituted by its three commissioners.

Senator XENOPHON: Given the matters that arose out of the Senate inquiry, the evidence that was given and that whole process and issues with respect to the MOU between CASA and the ATSB, for instance, and other matters about the downgrading of the nature of the report from critical to a minor safety incident, do you think in those circumstances it would be preferable for public confidence in the ATSB for there to have been an impartial arbiter or impartial advice sought from an expert to give advice to the ATSB in respect of that, rather than the commissioners basically just making a judgment call as to whether it ought to be amended or reopened based on your previous judgments? You can understand why there might be some concern about that.

Mr Dolan : I understand the concerns. All I can reiterate is that the responsibility for making those judgments by law rests with the ATSB and we will continue to exercise our responsibilities under the act.

Senator XENOPHON: I understand your responsibilities under the act, but do you consider it preferable in terms of the public confidence in the ATSB, given the highly critical nature of the Senate committee's report with respect to the Pel-Air incident and criticisms from others who gave evidence to the inquiry, that it would not be unreasonable for the ATSB to have sought an independent entity to provide advice before you considered whether there was something new and significant in the context of reopening any investigation into the Pel-Air incident?

Mr Dolan : The three commissioners determined that it was their responsibility to make that assessment and we did not see any need or possibility to defer that decision to someone else. What we did do, quite deliberately, was ask a counterpart organisation, the Transportation Safety Board of Canada, to benchmark our investigation methodology against their investigation methodology and to review three of our investigations in light of that, essentially against what the TSB would have done as against what we did, and to give us an independent report on the results. It is entirely possible that as a result of that there will be new and significant information. If there is, the commission will reopen the investigation.

Senator XENOPHON: It goes beyond methodology, does it not, because looking at the methodology of the ATSB is a little different from the reality of how the ATSB may or may not have implemented that methodology.

Mr Dolan : Very much beyond the methodology and into how it was applied.

Mr Mrdak : I think going back to my earlier answer about the integrity of the process, the terms of reference that have been given to the Transportation Safety Board of Canada, the way in which they are looking at that and the advice to government from the ATSB on that process will underpin the government's response when that is tabled in terms of the very questions you are asking.

Senator XENOPHON: You would understand the disquiet in the aviation community that the ATSB was effectively Caesar judging Caesar. The commissioners had to make a determination as to whether they did a good job or not in terms of their previous report that was the subject of scathing criticism by a Senate inquiry. But you acknowledge that?

Mr Mrdak : I understand that and I have certainly closely reviewed the Senate inquiry report, but I think Mr Dolan has set out for you that seeking the advice from the Canadian authorities is the way in which the ATSB has sought to deal with a number of the issues raised in the Senate committee report.

The fact that the depth of dysfunctionality in both CASA and the ATSB has been allowed to reach the levels it has by both Albanese then Truss is a total disgrace, but no matter how much effort's expended here on PPRuNe, no-one in Cantberra seems to be listening - or actually DOES give a shit.

Abbott's indicated that he's totally unprepared to listen to, or do anything about, anything that he doesn't agree with ..... unless there are a significant number of dissenting voices that convince him he's dead in the water unless he DOES take meaningful action to address the concerns being expressed.

From what I can see, the Abbott government is now acting in response to obvious 'pressure points', so maybe it's time for the aviation industry to now really start applying some pressure - through, as Sunfish says, marginal seats.

Unless Dick Smith is prepared to use his influence in the Howard/Credlin government or support a popular candidate against Barnaby Joyce in his electorate, the only tiny glimmer of hope is the non-major party aligned Senators.

At least people are finally realising that the Laborials really don't care two stuffs. As far as they are concerned, CASA, ATSB and Airservices are doing their real jobs really well.